History taking (History of Physical Examination)

A History of Physical Examination Texts and the Conception of Bedside Diagnosis. ... Throughout this paper we construct a difference between a “bedside diagnosis,” made when the physician and patient are in each other's presence, and a “remote diagnosis,” made when the patient and physician are separated.

1. HISTORY TAKING PRESENTED BY PANKAJ SINGH RANA NURSE PRACTITIONER

2. INTRODUCTION There are many situations in which the patient may be unable to give a history (e.g., they are unconscious, delirious, demented, or dysphasic). In these situations, health care member should make an effort to speak to all who can help to fill in the gaps regarding what happened to the patient.

3. When taking a history from a source other than the patient, be sure to document clearly that this is the case and the reason(s) for the patient being unable to speak for themselves. Useful sources of information include the following: Relatives, guardians, and cohabitants Close friends and roommates Primary care physician (PCP) or other members of the primary care team  Pharmacist Staff at the nursing home or residential or other facility Ambulance personnel Anyone who witnessed the event.

4. PATIENT PROFILE This is the essential identifying and biographic information required by the facility. Typically included in the PP will be the patient’s name, address, and DOB. Other information included in the PP may include age, religion, nationality, marital status, and contact information as requested by the individual facility.

5. CHIEF COMPLAIN This is the patient’s chief symptom(s) in their own words. It should generally be no more than a single sentence. If the patient has several symptoms, present them as a list that can expand on later in the history. Ask the patient an open question, such as, “What’s the problem?” or “What made you come to the hospital?”

6. HISTORY OF THE PRESENTING ILLNESS Here you are asking about and documenting details of the presenting complaint. By the end of taking the HPI, you and readers of the record should have a clear idea about the nature of the problem and of exactly how and when it started, how it has progressed over time, and what impact it has had on the patient in their general physical health, psychology, and social and working lives. The HPI is best tackled in two phases. First, ask an open question (as for the CC) and allow the patient to talk through what has happened for about 2 minutes. Don’t interrupt! Encourage the patient with nonverbal responses and take discreet notes. This allows you to make an initial assessment of the patient in terms of education level, personality, and anxiety. Using this information, you can adjust your responses and interaction. It should also become clear to you exactly what symptom the patient is most concerned about.

7. In the second phase, you should revisit the whole story, asking more detailed questions A mnemonic for remembering the important factors in analyzing pain or a symptom is O3PQRST. Onset, Previous occurrences, Provoking factors, Palliative factors (including prescribed and home treatments attempted), Quality (such as characteristics of pain), Radiation (site of onset and any radiation), Severity, and Timing

8. For pain, determine Site (where is the pain is worst—ask the patient to point to the site with one finger) Radiation (does the pain move anywhere else?) Character (i.e., dull, aching, stabbing, burning) Severity (scored out of 10, with 10 being the worst pain imaginable) Mode and rate of onset (how did it come on—over how long?) Duration Frequency Exacerbating factors Relieving factors Associated symptoms (e.g., nausea, dyspepsia, shortness of breath )

9. PAST MEDICAL HISTORY Some aspects of the patient’s past illnesses or diagnoses may have already been covered. Here, you should obtain detailed information about past illnesses and surgical procedures. When was it diagnosed? How was it diagnosed? How has it been treated?

10. SPECIFIC CONDITIONS TO INCLUDE IN PAST MEDICAL HISTORY Diabetes Rheumatic fever Jaundice Hypercholesterolemia Hypertension Angina Myocardial infarction (MI) Stroke or transient ischemic attack (TIA) Asthma Tuberculosis (TB) Epilepsy Anesthetic problems Blood transfusions Childhood illnesses and sequelae

11. ALLERGIES Any allergies should be documented separately from the drug history because of their importance. Ask if the patient has any allergies or is allergic to anything if they are unfamiliar with the term allergies . Be sure to probe carefully, as people will often tell you about their hay fever and forget about the rash they had when they took penicillin. Ask specifically if they have had any reactions to drugs or medication; don’t forget to inquire about food or environmental allergies.

12. DRUG HISTORY Here you should list all the medications that the patient is taking, including the dosage and frequency of each prescription. If the patient is unsure about their medications. Eye drops Inhalers Sleeping pills Oral contraception OTC drugs (bought at a store or pharmacy), vitamin supplements Herbal remedies Illicit or “recreational” drug use

13. ALCOHOL You should attempt to quantify, as accurately as possible, the amount of alcohol consumed per week, and establish if the consumption is spread out evenly over the week or concentrated in a smaller period. Alcohol amounts of common drinks For typical strength alcoholic beverages the following contain approximately 0.54 ounces of ethanol. 12 ounces beer 5 ounces of wine 1.5 ounces of 80 proof distilled spirits

14. SMOKING Attempt to quantify the habit in pack-years: 1 pack-year is 20 cigarettes (1 pack) per day for 1 year (e.g., 40/day for 1 year = 2 pack-years; 10/day for 2 years = 1 pack-year). ask about passive smoking

15. FAMILY HISTORY The FH details the following: Makeup of the family, including age and gender of parents, siblings, children, and extended family, as relevant Health of the family document the age and cause of death for all deceased first-degree relatives and for other family members felt appropriate.

16. FAMILY TREE

17. SOCIAL HISTORY This is to document the details of the patient’s personal life that are relevant to the working diagnosis, the patient’s general well-being, and recovery or convalescence. The Social History will help in understanding the impact of the illness on the patient’s functional status. Marital status Sexual orientation Occupation (or previous occupations if retired) Does the patient own their accommodation or rent it? Are there any stairs? How many?

18. Does the patient have any aids or adaptations in their house (e.g., rails near the bath)? Does the patient receive any help on a daily basis? Does the patient have relatives living nearby? What hobbies does the patient have? Does the patient own any pets? Has the patient been abroad recently or spent any time abroad in the past? Does the patient drive?

19. REVIEW OF SYSTEMS Prior to the exam, you should perform a screening of the other body systems relevant to the chief complaint. When conducting the comprehensive exam, review of all systems is necessary and use of a cranial–caudal approach to the review may be most appropriate. Not only is the finding of unexpected symptoms important, the absence of particular symptoms may be of even greater significance, therefore, always document significant negatives .

20. The questions asked will depend on any previous discussion(s). General symptoms   Weight change (loss or gain), change in appetite (loss or gain), fever, lethargy, malaise Skin symptoms Lumps, bumps, sores, ulcers, rashes, itch Sensory symptoms Vision problems hearing deficits Respiratory symptoms Cough, sputum, hemoptysis , shortness of breath, wheeze, chest pain

21. Cardiovascular symptoms Shortness of breath on exertion, paroxysmal nocturnal dyspnea , chest pain, palpitations, ankle swelling, orthopnea , claudication Gastrointestinal symptoms   Dysphagia , indigestion, abdominal pain, nausea, vomiting, a change in bowel habit, constipation, diarrhea, rectal blood loss Genitourinary symptoms   Urinary frequency, polyuria , dysuria , hematuria , nocturia , menstrual problems, impotence

22. Neurological symptoms Headaches, dizziness, tingling, weakness, tremor, faint, seizures, convulsions, epilepsy, blackouts or other loss of consciousness   Psychological symptoms Depression, anxiety, sleep disturbances   Endocrine symptoms Intolerance to heat or cold Musculoskeletal symptoms Aches, pains, stiffness, swelling